Saving patients or pumping premiums? Bill seeks to boost copay help in Ohio [Journal-News, Hamilton, Ohio]

Dec. 12--Approval of a new rule aiming to cut patients' costs for high-priced drugs hinges on getting a bill out of the Ohio Senate Health Committee in the next week or so.

Patient copays for prescription drugs go toward meeting those patients' annual insurance deductibles. But if patients get help with copays via coupons from drug manufacturers or charitable donations, some insurers and pharmacy benefit managers don't apply that assistance toward deductibles. That's called using a "copay accumulator."

For people whose conditions require very expensive drugs, that can add thousands of dollars to the cost of just one prescription, and greatly delay meeting their annual deductible.

House Bill 135 would require insurers and benefit managers to apply all copay assistance -- whether discount coupons from drugmakers or cash from donations -- toward patients' deductibles.

"It is a bill for patients," said state Rep. Susan Manchester, R-Waynesfield, one of HB 135 s sponsors.

She has heard from many patients who couldn't get the medication they needed due to copay accumulators or who faced huge payments for each prescription.

The bill exempts cases in which there is a generic equivalent but a doctor prescribes a name-brand drug. It doesn't require insurers to cover a drug that isn't already on its coverage list and says withdrawing coverage of a drug isn't a violation unless it breaks other laws.

Manchester and state Rep. Thomas West, D-Canton, introduced HB 135 in February, and it passed the House unanimously in March. Since then it's been in the Senate Health Committee, where it had a second hearing Nov. 30 but did not get a final vote. The question is whether it will be back for more hearings this week.

"I haven't seen a committee schedule yet, so it's hard to say," Manchester said Thursday.

Helen Bisdorf, a Butler County resident, said she handled finding health insurance for about 10 employees of the business she and her husband owned. That included herself. Bisdorf has multiple sclerosis and other chronic conditions.

Even though she already knew to look for plans that didn't have copay accumulators, many insurance agents didn't seem to know what they were, Bisdorf said. It wasn't easy to find plans that credited copay assistance toward deductibles, she said.

The Bisdorfs sold their business in 2021, but she now works with a group of MS patients in the Cincinnati area, and many of them struggle to access or pay for treatment, she said.

"There's over 20 disease-modifying therapies for MS and the average cost for them is $80,000 a year," Bisdorf said.

Opposing views

When the bill came through the House, opponents only offered written testimony, Manchester said.

"We have not had an opponent hearing yet in the Senate," she said. Opposition so far has been the familiar claim that eliminating copay accumulators will raise insurance premiums, Manchester said. But the example of other states that have passed similar legislation shows that banning copay accumulators has "little to no effect on their premiums," she said.

Three groups submitted testimony against the bill in a March committee hearing, while the bill was still in the House: the Pharmaceutical Care Management Association, Ohio Association of Health Plans and America's Health Insurance Plans.

Connor Rose of PCMA, which represents administrators of prescription drug plans, says copay accumulators "thwart drug manufacturers' efforts to force (insurers) to pay for unnecessary brand medications through the use of copay coupons."

He said the PCMA doesn't oppose "means-tested patient assistance programs" or cash from a church or relative applying toward a patient's deductible, just copay coupons from drug manufacturers.

"These coupons increase the share of prescriptions that are filled by a branded drug by over 60%," pumping up drugmakers' profits, according to Kelly O'Reilly of OAHP, the state's leading trade association for health insurers.

"In providing copay coupons, the drug manufacturer's goal is to have an individual meet their deductible as quickly as possible," O'Reilly's testimony said. "Once an individual meets their deductible, the drug manufacturer charges the individual's insurance for the full price of the drug."

Mary Haffenbredl of AHIP said copay coupons are only offered to patients who have a limited choice of drugs, and only until their deductibles are met.

All the opponents said Medicare and Medicaid ban the use of copay coupons.

In the bill's most recent hearing, state Sen. Steve Huffman, R-Tipp City, the Health Committee chair, pushed repeatedly to add a requirement that drugmakers offer copay coupons for 12 months at a time.

That idea also came up in House hearings, Manchester said.

"We felt that that wasn't an appropriate piece to put in the legislation," she said. As she told Huffman when the bill was first heard, if a one-year copay coupon guarantee is added to the bill, so should a requirement that insurance companies keep patients' doctors on their list of covered providers and keep medications on their list of covered drugs for the same period, Manchester said.

Patients' pleas

Randi Clites, a former state legislator now with the Ohio Bleeding Disorders Council, testified Nov. 30 that her son's hemophilia medication costs "easily $400,000 a year."

That mean an out-of-pocket expense of about $3,000 a year for her family, which they'd met for 30 years, Clites said. But her husband's employer stopped offering family coverage so she signed up for the one available Ohio plan that didn't have a copay accumulator.

Her son's first prescription under the new plan cost $7,900 out of pocket, Clites said.

"That is when we had to start to depend on copay assistance," she said.

Clites switched to a new plan last year only to find it had a copay accumulator under a different name. For the first time, the copay assistance her son received didn't go toward his out-of-pocket maximum, and dealing with the huge resulting bill slowed down his essential medication delivery, Clites said.

The use of copay accumulators started about 2017, Mark Thompson of the Community Oncology Alliance said in a letter to Huffman.

Fifteen states prohibit not counting copay assistance toward deductibles, and another 20 are working on it, Thompson said. Those states show no evidence that banning copay accumulators hikes insurance premiums, he said.

"Of those Ohioans receiving copay assistance, 70% are working Ohioans who make less than $40,000 per year," Thompson said.

Nine of the 10 federal healthcare marketplace plans available in Ohio use copay accumulators, according to a Nov. 15 letter from a dozen Ohio healthcare providers to the Health Committee.

"99.6% of all medications which receive third-party copay assistance have no generic options," the letter said.

Leo Almeida of the American Cancer Society said more than 73,000 Ohioans will be diagnosed with cancer this year, and many will need drugs for which there are no generic equivalents.

Copay coupons are mostly used for patients with rare diseases or chronic conditions that need specific, very expensive drugs for a long time, said Kristina Moorhead from the Pharmaceutical Research and Manufacturers of America trade group.

Multiple sclerosis patients often need to switch between costly medications to deal with the unpredictable disease, said Holly Pendell of the National MS Society.

Christine Pfaff, pharmacist at the Zangmeister Cancer Center, said she has seen patients skipping or stopping medication because they can't afford it.

Megan Jackson of Springboro submitted testimony for the Nov. 30 hearing. Multiple chronic medical conditions leave her unable to work.

"In 2022 alone, I have charged more than $6,000 on my credit cards for medical and pharmaceutical copays. I have spent $10,000 on copays this year," Jackson wrote.

One of her medications costs $24,000, of which her insurance covered less than $16,000.

"Thankfully, with copay assistance I only had to pay $5. So, how much went toward my insurance deductible? $5. Even though $8,455 was paid through copay assistance and myself, my insurance company only allowed my $5 payment to be applied to my deductible.

"If things continue the way they are I likely won't be able to continue seeking all the care I need."

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